Basic Information
| Provider Information | |||||||||
| NPI: | 1891963880 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN HOME CARE SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9901 LINN STATION RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402233808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008660860 | ||||||||
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| Practice Location | |||||||||
| Address1: | 990 E MAIN ST | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | BLUE RIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305134565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062582695 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2008 | ||||||||
| LastUpdateDate: | 07/08/2016 | ||||||||
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| AuthorizedOfficialLastName: | PANK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PARALEGAL | ||||||||
| AuthorizedOfficialTelephone: | 5024202666 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 000552538Q | 05 | GA | MEDICAID |